Failure to Safeguard and Account for Controlled Medication
Penalty
Summary
A deficiency occurred when a nurse (LPN) failed to properly account for a resident's controlled medication, specifically Lorazepam tablets. The nurse reported that after administering a dose, she accidentally discarded the entire bottle containing 10 remaining tablets into the garbage. This was discovered during the routine narcotic count, which revealed the bottle was missing. The nurse admitted to possibly giving another dose in the morning and stated she realized the error only during the count. Video footage confirmed the nurse was seen preparing medications and discarding the bottle, but did not show her administering the medication. The resident involved was unable to communicate whether the medication was received, and the medication was supplied in bottles by hospice. The facility's policy requires staff to remain in the area until all discrepancies are resolved or reported as unresolved, but the nurse left the building before the issue was fully addressed. Other staff members noted the nurse's unusual behavior and that she had access to multiple medication carts. The missing medication was not recovered, as the garbage had already been removed. Documentation showed the medication was last signed out for administration, but the remaining tablets were unaccounted for, resulting in a failure to safeguard the resident's controlled substances as required.